MEDICARE: HAVASU RAINBOW PEDIATRICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center		AZ

General Provider Information

NPI Number	:	1437340098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVASU RAINBOW PEDIATRICS

Provider Business Mailing Address
First Line	:	1980 MESQUITE AVE STE 101
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-7713
Country	:	US
Telephone Number	:	928-680-1919
Fax Number	:	928-680-0488

Provider Business Practice Location Address
First Line	:	1980 MESQUITE AVE STE 101
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-7713
Country	:	US
Telephone Number	:	928-680-1919
Fax Number	:	928-680-0488

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. MARIA B OYAS
Credential	:
Telephone Number	:	928-680-1919

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	07/21/2022

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